Quality Medical Auditor

Internal Reference Number: R1051186
Summary Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events (serious, preventable medical errors) for all lines of business. Coordinates rate adjustments with claims areas. Provides monthly and quarterly reports outlining trends. Serves as a resource in resolving coding issues. Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department.Description

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose:

Performs validation reviews of Diagnosis Related Groups (DRG), Ambulatory Procedure Codes (APC), and Never Events (serious, preventable medical errors) for all lines of business. Coordinates rate adjustments with claims areas. Provides monthly and quarterly reports outlining trends. Serves as a resource in resolving coding issues. Coordinates HIPAA and legal records requests for all areas of Healthcare Services and the Legal Department.

Location:

This position is a remote position, and the hours are Monday - Friday from 8:30am - 5pm EST.

Sponsorship :

This position is not eligible for sponsorship now or in the future.

What You 'll Do:

• Determines methodology to identify cases for validation review. Conducts validation reviews/coordinates rates adjustments with appropriate claims area. Creates monthly/quarterly reports to present to each line of business providing information on records review, outcomes, trends, and savings that directly impact medical costs and contracting rates.
• Manages records retrieval, release, HIPAA compliance, and all aspects of document management.
• Serves as expert resource on methodology and procedures for medical records and coding issues.

To Qualify F or This Position, You'll Need T he Following:

• Required Education: Associate's in a job related field
• Degree Equivalency: 2 years job related work experience.
• Required Work Experience: 3 years medical record management to include coding and validation review experience.
• Skills and Abilities: Excellent verbal and written communication, organizational, customer service, and analytical or critical thinking skills. Good judgment. Ability to handle confidential or sensitive information with discretion. Extensive medical records and coding knowledge. Working knowledge of contract evaluations, claims processing and adjudication practices.
• Required Licenses and Certificates: Registered health information administrator (RHIA) OR Registered health information technician (RHIT) OR Certified Professional Coder (CPC) OR Certified Inpatient Coder (CIC) OR Certified Professional Medical Auditor (CPMA) OR, active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

We Prefer That You Have T he Following :

• Prior TrueCode experience.
• Ability to process between 5 and 7 cases per day.

OurComprehensiveBenefitsPackageIncludesTheFollowing:

We offer our employees great benefits and rewards.You will be eligible toparticipateinourbenefitsprogramthe first of the month following28 daysof employment.

• Subsidized health plans, dental and vision coverage

• 401kretirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• EducationAssistance

• Service Recognition

• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrumshave the opportunity todevelop their skills, advance their careers and contribute their unique abilities to the growth of our company.

WhatTo Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications.This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's moreinformation.

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